Autonomy Support at Diabetes Camp: A Self Determination Theory Approach to Therapeutic Recreation

Adolescents with type 1 diabetes struggle to effectively manage their illness. Failure to take responsibility for regulating glycemic levels can lead to a number of very significant physiological, psychological, and social problems. This study employed a Benefits-Based Programming (BBP) approach and self-determination theory (SDT) to target outcomes through a recreation camp setting. The SDT provided researchers with a theoretical framework that focused on the internalization of diabetes management. The camp setting was chosen because annually diabetes camps serve more than 10,000 adolescents. Empirical evidence supports the use of theory-based camping for therapeutic purposes among adolescents with disabilities and illnesses to increase self-esteem, self-image, and self-determined behaviors (Brannan, Fullerton, Arick, Robb, & Bender, 2002; Mahon, 1994; Marsh, 1999). The results of this theory-based study can be used by recreation therapists and recreation programmers to help increase the effectiveness of other diabetes camps. Results of the regression equations showed perceived autonomy support to be significantly and uniquely related to the predicted outcome variable (e.g., competence for diabetes management).

KEY WORDS: Self-determination theory (SDT), self-management, internalization, type 1 diabetes, Benefits-Based Programming (BBP), summer camp, and motivation.

Purpose of the Study

Physicians assert that people with type 1 diabetes should provide 95% of the behavioral management for their own disease. Existing evidence, however, indicates that adolescents manage less than 20% of their diabetes (Anderson, 1985). Failure to internalize behaviors and take responsibility for regulating glycemic levels can lead to a number of very significant physiological, psychological, and social problems. Poor management of glycemie levels can lead to aggression, antisocial conduct, anxiety, depression, kidney failure, stroke, nontraumatic amputations, and death (Bryden, Peveler, Stein, Neil, Mayou, & Dunger, 2001).

A Benefits-Based Program may lessen adolescents' poor management of type 1 diabetes. Benefits-Based Programming (BBP) emphasizes the use of a theoretical framework to target outcomes through recreation programs (Hurtes, Alien, Stevens, & Lee, 2000). A key to the success of such programs for adolescents with diabetes is the facilitation, production and execution of recreation experiences that are explicitly designed to help those individuals internalize behaviors for self-management. Benefits-based programming also emphasizes the importance of using intentionality and theoretical frameworks.

Self-determination theory states that behaviors are autonomously motivated to the extent that people experience a true sense of volition and choice (Deci & Ryan, 2000; Williams, Rodin, Ryan, Grolnick, & Deci, 1998). It is unlikely that management of behaviors for adolescents with diabetes will be truly intrinsically motivated. Therefore, addressing extrinsic motivation may be the most effective way to increase internalized behavior (Deci & Ryan, 2000). "At this point [internalization] of the individual's behavior has been brought into congruence with one's values and needs" (Deci & Ryan, 2002, p. 201). Internalization, for the purpose of the study, is defined as behaviors that are congruent with one's own values. Self-determination theory (SDT) provides a framework to explain what is needed for diabetes self-management behaviors to become internalized.

Empirical evidence supports the use of theory-based therapeutic camping for adolescents with disabilities and illnesses to increase selfesteem, self-image, and self-determined behaviors (Brannan, Fullerton, Arick, Robb, & Bender, 2002; Mahon, 1994; Marsh, 1999). Camping programs for people with diabetes serve more than 10,000 adolescents annually (American Diabetes Association, 2003). Therefore, the purposes of this study were to examine both the effects of an intentional, summer camp recreation program on internalization of type 1 diabetes management behaviors among adolescents and the role that autonomy support plays in diabetes management.

Review of Literature

Type 1 Diabetes

An increasing number of adolescents are being diagnosed with type 1 diabetes, but are unable to effectively manage their illness (Byrden et al., 2001). Type 1 diabetes develops when the body's immune system destroys pancreatic beta cells, the only cells in the body that produce the hormone, insulin. Treatment requires the injection of insulin through a syringe or pump several times a day. Unfortunately, adolescents struggle to make the connection between careful self-management skills practiced in adolescence and the impact on quality of life as an adult. When glycemic control deteriorates from childhood to young adulthood, individuals are at risk of developing short and long-term complications (Byrden et al., 2001; Mann & Johnston, 1982). Shortterm health complications for adolescents with type 1 diabetes can lead to immediate problems at school, home, and in recreation activities.